Computed Tomography Cystogram

CLINICAL EXAMPLE 1: Computed Tomography Cystogram CLINICAL HISTORY Bladder cancer. Residual urine leak. TECHNIQUE A Foley catheter was inserted in the radiology department. Subsequently, a computed tomography (CT) scan of the pelvis was performed prior to and after contrast was instilled into the urinary bladder via the Foley catheter without the administration of contrast intravenously. COMPARISON CT pelvis 4/8/2018. FINDINGS Pre-contrast images show a left ureteral stent extending into the urinary bladder. The urinary bladder is decompressed with a Foley catheter. A drainage catheter is located outside of the bladder in the left-lower quadrant, just anterior to the left...

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Note:  The following article synopsis was NOT provided by the AMA. It was created by Find-A-Code/innoviHealth.

Article Overview

This premium coding article discusses how computed tomography cystogram studies are described and reported in radiology documentation. It focuses on how the exam type, anatomic area, and contrast approach affect coding, and it includes related diagnosis coding context and references to professional guidance. The article is intended for coders, radiology staff, and auditors who need to understand how this type of study is documented and classified.

Why This Topic Matters

CT cystogram studies can be documented in ways that affect code selection and claim accuracy. Understanding the distinctions discussed in the article helps readers evaluate whether the report supports the intended coding approach and whether the documentation is sufficiently specific for radiology billing and audit review.

Article Sections

  1. Clinical Example 1

    A radiology example presents the clinical context, imaging approach, findings, and impression for a CT cystogram study.

  2. How to Code

    This section provides the coding-related discussion tied to the example and the associated documentation considerations.

  3. Discussion

    This section reviews general CT reporting concepts, terminology used for cystogram-type studies, and related coding guidance sources.

  4. Sources

    This section lists the professional references cited by the article.

What You Will Learn

  • How the article frames CT cystogram documentation for coding review
  • Which general code sets are discussed in relation to the example
  • How exam naming and anatomic specificity are addressed in radiology coding guidance
  • What documentation themes are highlighted for Foley catheter and bladder imaging studies

Who Should Read This

  • Medical coders
  • Radiology coders
  • Compliance auditors
  • Radiology billing staff
  • Physicians documenting imaging studies

Codes Discussed


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